1679627798 NPI number — DR. BRETT W. GOUDIE MD

Table of content: PATRICIA I DELGADO MD (NPI 1003888165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679627798 NPI number — DR. BRETT W. GOUDIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOUDIE
Provider First Name:
BRETT
Provider Middle Name:
W.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679627798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
593 EDDY ST
Provider Second Line Business Mailing Address:
HASBRO 122
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02903-4923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-444-4612
Provider Business Mailing Address Fax Number:
401-793-8831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 HOPPIN ST
Provider Second Line Business Practice Location Address:
CORO BUILDING
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02903-4141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-444-4612
Provider Business Practice Location Address Fax Number:
401-793-8831
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X , with the licence number:  C10008082 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: D0068007 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: MD429590 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: RI13511 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109592 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1679627798 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4110510 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101712508 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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